Healthcare Provider Details

I. General information

NPI: 1639113574
Provider Name (Legal Business Name): JUANITA S. JOHNSON L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W BANK ST SUITE 5
PETERSBURG VA
23803-3279
US

IV. Provider business mailing address

1093 ASBURY CHURCH RD
HALIFAX VA
24558-2947
US

V. Phone/Fax

Practice location:
  • Phone: 804-863-1689
  • Fax: 804-863-1695
Mailing address:
  • Phone: 434-476-7139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number07010026
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: